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Broker Website Registration

Website registration gives you access to the full site, allows you to get answers for your clients about coverage and eligibility, provides sales support tools, and more. To properly access the full site, please ensure Brokerage/Agency Firms contract with Health Net first, so that your individual brokers and consultants can register for the site and be properly associated to the correct firm.

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Terms of Use


This Terms and Conditions of Use Agreement ("Agreement") is a legal agreement between you and Health Net, Inc. ("Health Net" or "we") governing your use of this Web site (the "site"). YOUR USE OF THIS SITE IS SUBJECT TO THE TERMS AND CONDITIONS OF THIS AGREEMENT. BY ACCESSING, USING AND/OR VIEWING OUR SITE, YOU HEREBY AGREE TO BE BOUND BY THE TERMS OF THIS AGREEMENT. IF YOU DO NOT AGREE TO THESE TERMS AND CONDITIONS, YOU MUST EXIT THIS SITE. PLEASE NOTE THAT CHILDREN UNDER THE AGE OF THIRTEEN (13) ARE PROHIBITED FROM USING ANY HEALTH NET SITE, INCLUDING THE TEEN HEALTH SITE. We may revise the information on the site or otherwise change or update the site, including this Agreement. If we make changes to this Agreement, we will use reasonable efforts to post such changes before they become effective and to specify the date they will become effective. In the absence of any specific date being provided, the changes are effective immediately. A current version of this Agreement showing the effective date is always available at this location. We encourage you to periodically read this Agreement to see if there have been any changes to our policies that may affect you. Health Net may also make improvements and/or changes in products and/or services described on this site or add new features at any time without notice. Your continued use of the site will signify your continued agreement to this Agreement as it may be revised. WEBSITE ACCESS; PROHIBITED ACTIVITIES. Provided that you are not under the age of thirteen (13), we hereby grant you a personal, non-exclusive, non-transferable, revocable license to access our site and the information contained within the site. Users under the age of thirteen (13) are prohibited from using the site. The site contains software tools and databases that allow you to search and retrieve information. You may not gain unauthorized access to the site, to other users' accounts, names or personally identifiable information, or to other computers or websites connected or linked to the site. You may not send or otherwise transmit to or through this site chain letters, unsolicited messages, so-called "spamming" or "phishing" messages, or messages marketing or advertising goods and services.


You may use our services for lawful purposes only. You may not use our services to post, transmit or otherwise distribute unlawful material. Examples of unlawful material include, but are not limited to, threats of physical harm, defamatory statements, pornographic material, and copyrighted, trademarked, and other proprietary material used without proper authorization. You may not post, transmit or otherwise make available any virus, worm, spyware or any other computer code, file or program that may or is intended to damage or hijack the operation of any hardware, software or telecommunications equipment. You may not "flood" or disrupt our site through any means or process such as launching or using any automated system, including but not limited to, "robots," "spiders," or "offline readers." You may not misrepresent your identity or affiliation in any way. You may not restrict, discourage or inhibit any person from using the site, disclose personal information on the site or obtained from the site or collect information about users of this site. You may not reverse engineer, disassemble or decompile any section or technology on the site, or attempt to do any of the foregoing. You are responsible for all use of our services and the site, with or without your consent, by yourself and others, which occurs by, through, or in connection with access to the site via your computer. REGISTRATION. You are not obligated to register with Health Net in order to access this site. However, certain sections and features of this site are available only to Health Net members, brokers, providers and employers ("Registered Users"). If you are a Registered User, you agree to accurately maintain and update any information about yourself that you have provided to Health Net. You also agree to promptly notify us of any unauthorized use of your username, password or any other breach of security that you become aware of involving or relating to this site. NO FEES FOR THIS SITE. Health Net does not charge you any fees for using its site, but you may incur charges from your online service provider and/or telephone or cable companies. ELECTRONIC DOCUMENT DELIVERY. Some members may elect to enroll in Health Net's electronic document delivery program. By enrolling, you consent to receive electronic delivery via www.healthnet.com, and to stop U.S. mail delivery of the paper versions of documents you select for electronic delivery. Your consent, when issued electronically by use of your personal information or passwords, bears the same legal authority as your written signature and is binding by law. You agree that you have full authority to accept the terms of this "Electronic Document Delivery" section on behalf of each beneficiary on your plan. You also agree that each beneficiary has full authority to act individually in all matters relating to this online service. You may still obtain a paper copy of any important member document listed above, at no charge, by contacting Health Net at the number listed on your member ID card. In addition, you may download/print a copy of any of these documents online by logging on to your account on www.healthnet.com. The time it takes to process your change from U.S. mail delivery to electronic document delivery varies depending on the documents you select, as does the amount of time the document is available on the site.


Explanation of Benefit's (EOB's). When you select these documents, we will reflect the change to electronic delivery within 48 hours on average, although it could take longer for U.S. mail deliveries already in progress to stop. As your EOB documents become available, notifications will be sent to your email address and they will remain on our site for up to 7 years. Evidence of Coverage (EOC's). When you select these documents, we will reflect the change to electronic delivery within 48 hours on average, although it could take longer for U.S. mail deliveries already in progress to stop. As your EOC documents become available, notifications will be sent to your email address and they will remain on our site for up to 7 years. Medicare Annual Notice of Change Materials (ANOC's). When you select these documents, we will reflect the change to electronic delivery within 48 hours on average, although it could take longer for U.S. mail deliveries already in progress to stop. As your ANOC documents become available, notifications will be sent to your email address and they will remain on our site for up to 7 years. Medicare Post Enrollment Materials. When you select these documents, we will reflect the change to electronic delivery within 48 hours on average, although it could take longer for U.S. mail deliveries already in progress to stop. As your Post Enrollment documents become available, notifications will be sent to your email address and they will remain on our site for up to 7 years. All Future Available Online Documents. When you select this option, we will notify you via email as new document types become available for electronic document delivery.


Please note: Not all document types listed above may apply to your respective plan. You must maintain a valid email address with Health Net as a condition of participating in our electronic document delivery program. Health Net will send an email to the address you've provided, to notify you when a new document is available on our site and indicate the category of document. The email will provide a link to a login page on our site's secure member portal. After you log in, your specific document(s) will be displayed. If we are unable to notify you via email when a document becomes available due to a bad and/or cancelled email account, we will attempt to contact you to update your email address. If we are unable to make contact with you, we will revert your Document Delivery Preferences back to U.S. mail delivery for all document types, and send a letter notifying you of the change. You can log into www.healthnet.com and update your email address and document delivery preferences at any time. Depending on your specific plan, some exceptions to electronic document delivery may apply. For example, all Health Net State Health Plan Members are unable to participate at this time. Members will continue to receive hard copies of any material that are currently unavailable in electronic form and/or if for any reason the electronic delivery process is unavailable for certain Health Net plans. You may cancel electronic document delivery for any category of documents at any time, by clicking the Change Document Delivery Preferences link and changing your document delivery choice to Mail (USPS) or by calling Health Net. You may also cancel all electronic delivery services and revoke your agreement to the terms of this "Electronic Document Delivery" section, by clicking the Change Document Delivery Preferences link and changing all your document delivery choices to Mail (USPS) or contact us. Your cancellation will be effective within a reasonable period of time after we receive it. Health Net may discontinue the electronic document delivery services we offer on this site. You understand that if you enroll in electronic document delivery your consent to the terms of this "Electronic Document Delivery" section will be effectively indefinitely, until you cancel electronic document delivery or it is cancelled by us. USER SUBMISSIONS. Health Net may offer users certain interactive features through the site from time to time. Interactive features may include the submission of commentary, feedback or other communications or materials by you and other users ("User Submissions"). Any personal information you submit to our site is governed by Health Net's Privacy Policy. This includes information on your rights to see and receive copies of your personal health information. To deactivate your www.healthnet.com account, please contact us. You agree, represent and warrant that any User Submission is a) truthful, accurate, and not misleading, b) offered in good faith, and c) that you have the right to transmit such information. Subject to the limitations of Health Net's privacy policy, you hereby grant to Health Net a perpetual, irrevocable, royalty-free, transferable right and license to use, copy, display, distribute, modify, and create derivative works based upon any content you submit, including the right to incorporate the content into any form, medium or technology throughout the world without compensation to you. You further voluntarily waive any "moral rights" you may have in such content.


Should you provide your email address in connection with your User Submission, you agree that Health Net and its third party service providers may use your email address to contact you about the content and for other administrative purposes. Members may use this site to view certain information from their Health Net history ("Health Net History") including, but not limited to, their medical claim history and prescription drug history (their "Personal Health Record"). Members may also populate their Personal Health Record by directly entering information into their Personal Health Record. If you think that the information included in your Personal Health Record that came from your Health Net History is inaccurate, you may contact Health Net using the customer service number listed on the back of your member ID card. Otherwise, Members may add, edit or delete portions of their Personal Health Record by accessing that particular section of their Personal Health Record and selecting to add a new entry, edit an existing entry or delete an existing entry or claim.


COPYRIGHT, TRADEMARKS & TRADE DRESS. All content included on the site, including but not limited to, any text, graphics and interactive features and any trademarks, service marks and logos contained therein (collectively "Materials") are owned by or licensed to Health Net, subject to copyright, trademark and other intellectual property rights under United States and foreign laws and international conventions. WebMD®, Health Dialog and Paradigm are registered trademarks/service marks of their respective owners and used on this site with permission. Health Net® and Decision Power are registered service marks of Health Net, Inc. and all rights are reserved. No Materials from the site may be copied, reproduced, republished, uploaded, posted, transmitted, or distributed in any way without written permission of the rights owner, except that you may use information purposely made available by Heath Net for downloading from this Site, provided that you (1) keep intact all copyright and other proprietary notices, (2) use such information only for your personal, non-commercial informational purpose and do not copy or post such information on any networked computer or broadcast it in any media, (3) make no modifications to any such information, and (4) do not make any additional representations or warranties relating to such information. You agree not to circumvent, disable, or otherwise interfere with security related features of this Site or features that prevent or restrict use or copying of any Materials or content.


Modification of any Materials or use of any Materials for any other purpose is a violation of the copyrights and other proprietary rights of Health Net, or of other entities or persons where so indicated, unless Health Net or the owner has provided said Material for such express purpose. Permission for all other uses of Materials contained herein, including reproducing and distributing multiple copies or using Materials on any other website or networked computer or linking to any page at this site except the "home page" (https://www.healthnet.com), must be obtained from Health Net or the appropriate rights owner in advance; otherwise, such use is prohibited. Requests for such authorization from Health Net should be submitted via an email to WCOE@healthnet.com. All design rights, databases and compilation and other intellectual property rights associated with this Site, in each case whether registered or unregistered, and related goodwill, are proprietary to Health Net.


THIRD PARTY CONTENT/LINKS. As you view the site, you may notice links to third-party websites. These links are for convenience only. If you use these links, you will leave this site. Certain of these linked websites may make use of Health Net proprietary intellectual property rights (such as copyrights, trademarks, service marks, logos and trade names) under license from Health Net. Health Net is not responsible for the availability or content of these other websites or for any viruses or other damaging elements encountered in linking to a third-party website. In addition, providing links to these websites should not be interpreted as endorsement or approval by Health Net of the organizations sponsoring such third-party websites or their products or services. This Agreement does not apply to any other websites. Members may have access to Decision PowerSM through their current enrollment with any of the following Health Net companies: Health Net of Arizona, Inc.; Health Net of California, Inc.; Health Net of Connecticut, Inc.; Health Net of New Jersey, Inc.; Health Net of New York, Inc.; Health Net Health Plan of Oregon, Inc.; Health Net Insurance of New York, Inc.; Health Net Life Insurance Company. In Arizona, benefits are underwritten and/or administered by Health Net of Arizona, Inc., for HMO plans and Health Net Life Insurance Company for indemnity plans and life insurance coverage. The Health Net of Arizona, Inc. service area includes all Arizona counties. Health Net, Inc., is the parent company of both Health Net of Arizona, Inc., and Health Net Life Insurance Company.


Decision Power is not part of Health Net's commercial medical benefit plans nor affiliated with Health Net's provider network and it may be revised or withdrawn without notice. Decision Power is part of Health Net's Medicare Advantage benefit plans but is not affiliated with Health Net's provider network. Decision Power services, including Health Coaches, are additional resources that Health Net makes available to enrollees of the above listed Health Net companies.


PRIVACY. Privacy and security are a very important part of the healthnet.com user experience. Health Net is required to follow Health Insurance Portability and Accountability Act (HIPAA) regulations for the use and disclosure of Protected Health Information (PHI). For more information, please review our Privacy Policy to understand our practices regarding your privacy in connection with our online services. DISCLAIMER. Our site contains various types of information originating from ourselves or third parties, including outside vendors that provide health-related information or goods and services. The site provides information about health issues designed to help users make better decisions. But medical information is not the same as medical advice. Although we go to great lengths to make sure our information is accurate and useful, we urge you to consult a physician if you want professional assurance that our information, and your interpretation of our information, is appropriate to your particular situation. AS THE USER OF THIS SITE, YOU ASSUME FULL RISK AND RESPONSIBILITY FOR ANY AND ALL USE OF THIS SITE, INCLUDING THE INFORMATION PRESENTED ON THE SITE. THE SITE IS INTENDED TO BE A GENERAL INFORMATION RESOURCE ONLY AND DOES NOT CONSTITUTE MEDICAL ADVICE AND IS NOT A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE OR TREATMENT. YOU ARE RESPONSIBLE FOR SEEKING PROFESSIONAL MEDICAL ADVICE IF YOU HAVE ANY QUESTIONS ABOUT YOUR HEALTH OR A HEALTH CONDITION. YOU AGREE TO HOLD HEALTH NET AND ITS AFFILIATES HARMLESS FROM ANY AND ALL CLAIMS RELATING TO YOUR USE OF, YOUR RELIANCE UPON, OR ERRORS OR OMISSIONS IN, INFORMATION FOUND ON THIS SITE. THE SERVICES, INFORMATION AND FUNCTIONS CONTAINED ON OUR SITE ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. WE EXPRESSLY DISCLAIM ANY AND ALL REPRESENTATIONS AND WARRANTIES, EXPRESS OR IMPLIED, INCLUDING THOSE OF ACCURACY, COMPLETENESS, NON-INFRINGEMENT, MERCHANTABILITY AND FITNESS FOR A PARTICULAR USE OR PURPOSE, CONCERNING OUR SERVICES OR THE ADEQUACY, ACCURACY OR COMPLETENESS OF THE INFORMATION OR SERVICES INCLUDED ON OUR SITE, THAT THE SERVICES WILL BE UNINTERRUPTED OR ERROR-FREE, THAT DEFECTS WILL BE CORRECTED OR THAT THIS SITE OR THE SERVER THAT MAKES IT AVAILABLE ARE FREE OF VIRUSES OR OTHER HARMFUL COMPONENTS. WE EXPRESSLY DISCLAIM LIABILITY FOR ERRORS IN OR OMISSIONS FROM SERVICES, INFORMATION, OR MATERIALS, INCLUDING HEALTH-RECORD HISTORIES, PRESCRIPTION AND NONPRESCRIPTION DRUG PURCHASE HISTORIES, OR PRESCRIPTION REFILL INFORMATION. WE ARE NOT RESPONSIBLE FOR THE CONTENT OF ANY LINKED WEBSITE OR ANY LINK CONTAINED IN A LINKED WEBSITE, EXCEPT TO THE EXTENT THAT SUCH WEBSITE OR LINK IS OWNED AND OPERATED BY HEALTH NET OR ITS AFFILIATE(S).


LIMITATION OF LIABILITY. Use of our services is at your own risk. With regard to outside vendors and information providers, we do not endorse, or otherwise recommend or approve any product or information located on or available through our site. We do not own or control other networks, sites, or hyperlinked sites outside of our own site, including the outside vendors accessed through our site. We have made reasonable efforts to validate that our lists of providers displayed are up to date and accurate. Please call the provider prior to scheduling an appointment to verify that the provider continues to be part of our network. We are not liable for any losses, damages, or non-covered charges as a result of using the provider locator tool or receiving care from a provider listed on our site. WE WILL NOT BE LIABLE TO YOU OR ANYONE ELSE FOR ANY HARM TO YOU OR OTHERS RESULTING FROM THE USE OF OUR SITE AND/OR THE PRODUCTS AND SERVICES PROVIDED THROUGH OUR SITE. TO THE MAXIMUM EXTENT PERMITTED BY LAW, IN NO EVENT WILL WE BE LIABLE TO YOU OR ANYONE ELSE FOR ANY SPECIAL, INCIDENTAL, DIRECT, INDIRECT, CONSEQUENTIAL OR PUNITIVE DAMAGES WHATSOEVER, INCLUDING, WITHOUT LIMITATION, DAMAGES FOR PERSONAL INJURY, WRONGFUL DEATH, LOSS OF REVENUE, BUSINESS INTERRUPTION, LOSS OF BUSINESS INFORMATION OR ANY OTHER PECUNIARY LOSS, LOSS OF TECHNOLOGY, LOSS OF RIGHTS OR SERVICES, LOSS OF DATA, INTERRUPTION OR LOSS OF USE OF ANY EQUIPMENT, MENTAL ANGUISH, EMOTIONAL DISTRESS, OR INVASION OF PRIVACY, ARISING OUT OF THE USE OF OR INABILITY TO USE OUR SITE AND/OR THE PRODUCTS AND SERVICES PROVIDED THROUGH OUR SITE, EVEN IF WE HAVE BEEN ADVISED OF THE POSSIBILITY OF SUCH DAMAGES, WHETHER UNDER THEORY OF CONTRACT, TORT (INCLUDING NEGLIGENCE), STRICT LIABILITY, OR OTHERWISE. WE ARE NOT RESPONSIBLE OR LIABLE FOR THE ACTS OR OMISSIONS OF OUTSIDE VENDORS OR INFORMATION PROVIDERS, OR FOR PERFORMANCE (OR NON-PERFORMANCE) WITHIN OUTSIDE NETWORKS OR INTERCONNECTION POINTS BETWEEN OUR SITE AND OTHER NETWORKS AND/OR SITES THAT ARE OPERATED BY THIRD PARTIES. WE ALSO MAKE NO REPRESENTATION REGARDING YOUR ABILITY TO TRANSMIT AND RECEIVE INFORMATION FROM OR THROUGH OUR SITE, AND YOU AGREE AND ACKNOWLEDGE THAT AT TIMES YOUR ABILITY TO ACCESS OUR SITE MAY BE IMPAIRED OR DISRUPTED. ALTHOUGH WE WILL USE COMMERCIALLY REASONABLE EFFORTS TO TAKE ANY ACTION WE CONSIDER APPROPRIATE TO REMEDY AND AVOID SUCH EVENTS, WE CANNOT GUARANTEE THAT THEY WILL NOT OCCUR, AND ACCORDINGLY WE DISCLAIM ANY AND ALL LIABILITY RESULTING FROM OR RELATED TO SUCH EVENTS. WE ARE NOT LIABLE FOR ANY FAILURE OR DELAY IN OUR PERFORMANCE DUE TO ANY CAUSE BEYOND OUR REASONABLE CONTROL, INCLUDING ACTS OF WAR, ACTS OF GOD, EARTHQUAKE, FLOOD, EMBARGO, RIOT, SABOTAGE, LABOR SHORTAGE OR DISPUTE, GOVERNMENTAL ACT OR FAILURE OF THE INTERNET.


INDEMNIFICATION. You agree to defend, indemnify and hold Health Net and its directors, officers, employees, agents, affiliates and successors harmless from and against any and all claims, demands, liabilities, judgments, losses, damages, costs, fees and expenses (including but not limited to reasonable attorneys' fees) arising from or relating to your use of the site or your acts or omissions, including but not limited to (1) infringement or misappropriation of any intellectual property rights, (2) defamation, libel, slander, obscenity, pornography, or violation of the rights of privacy or publicity, (3) spamming, or any other offensive, harassing or illegal conduct or violation of this Agreement, or (4) any damage or destruction to our site, to us, or to other persons or parties.


TERMINATION AND INVESTIGATION. Health Net may terminate the license granted to you under the above " Website Access; Prohibited Activities" section at any time if you are in breach of this Agreement. The license will terminate immediately without notice from Health Net if, in Health Net's sole discretion, you fail to comply with any term or provision of this Agreement. Upon such termination, you may not access, use, or view the site. Health Net expressly reserves the right, in its sole discretion, to terminate a Registered User's www.healthnet.com account due to any act that would constitute a violation of this Agreement. We reserve the right to investigate suspected violations of this Agreement. If we become aware of possible violations, we may initiate an investigation that may include gathering information from you or any user involved and the complaining party, if any, and examination of other material. We may suspend the provision of our services temporarily, or we may permanently remove the material involved from our servers, provide warnings to you, or suspend or terminate your access to our services. We will determine what action will be taken in response to a violation on a case-by-case basis, and at our sole discretion. We will fully cooperate with law enforcement authorities in investigating suspected lawbreakers. BREACH. You hereby acknowledge that your breach of this Agreement may result in immediate and irreparable harm to Health Net, for which there will be no adequate remedy at law, and that Health Net shall be entitled to equitable relief to compel you to cease and desist all unauthorized use, evaluation and/or disclosure of information obtained through the site. Your breach of this Agreement may also entitle Health Net to bring an action against you for any and all other remedies available at law or in equity. JURISDICTION. We operate and control our site from our location in California, United States of America. We make no representation that any information, materials or functions included on or through our site are appropriate for use in any other jurisdiction. If you choose to access our site from locations other than California, you do so on your own initiative and are responsible for compliance with applicable laws and regulations. This Agreement, and the rights and obligations of you and Health Net hereunder, shall be governed by, and construed in accordance with, the laws of the State of California and the guidelines created by the Centers for Medicare and Medicaid Services (CMS). You further agree that any legal action or proceeding between you and Health Net arising out of or relating to this Agreement or your use of the site shall be brought exclusively in a federal or state court of competent jurisdiction sitting in Los Angeles, California, and you hereby expressly and irrevocably consent to the jurisdiction and venue of such courts. NO WAIVER; SEVERABILITY. A waiver of any breach of any provision of this Agreement shall not be deemed to be a waiver of any repetition of such breach or in any manner affect any other terms or conditions of this Agreement. In the event that any provision of this Agreement is held to be unenforceable, it will not affect the validity or enforceability of the remaining provisions and will be replaced by an enforceable provision that is the closest to the intention underlying the unenforceable provision. ASSIGNABILITY. We may assign our rights and delegate our duties under this Agreement either in whole or in part at any time, at our sole discretion, and without your consent. You may not assign, sublicense or otherwise transfer your rights or obligations, in whole or in part, under this Agreement to anyone else. RELATIONSHIP. This Agreement does not establish any relationship of partnership, joint venture, employment, franchise or agency between you and us. Thank you for taking the time to review this Agreement. We look forward to providing services to you.

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Important Notice

General Purpose
Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service, or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the Member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether, under the facts and circumstances of a particular case, the proposed procedure, drug, service, or supply is medically necessary. The conclusion that a procedure, drug, service, or supply is medically necessary does not constitute coverage. The Member's contract defines which procedure, drug, service, or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net's National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment and services. In order to be eligible, all services must be medically necessary and otherwise defined in the Member's benefits contract as described in this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the Member's benefits, nor is it intended to dictate to providers how to practice medicine.


Policy Effective Date and Defined Terms.
The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative.


Policy Amendment without Notice.
Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior notice or website posting is required before an amendment is deemed effective.


No Medical Advice.
The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to Members. Members should consult with their treating physician in connection with diagnosis and treatment decisions.


No Authorization or Guarantee of Coverage.
The Policies do not constitute authorization or guarantee of coverage of any particular procedure, drug, service, or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations and dollar caps apply to a particular procedure, drug, service, or supply.


Policy Limitation: Member's Contract Controls Coverage Determinations.
Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service, or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the Member's contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member's contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member's contract shall govern. The Policies do not replace or amend the Member contract.


Policy Limitation: Legal and Regulatory Mandates and Requirements
The determinations of coverage for a particular procedure, drug, service, or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern.


Reconstructive Surgery
California Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. "Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:


1. To improve function; or
2. To create a normal appearance, to the extent possible.


Reconstructive surgery does not mean "cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance.


Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery.


Reconstructive Surgery after Mastectomy
California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the copayment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon.


Policy Limitations: Medicare and Medicaid
Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service, or supply for Medicare or Medicaid Members shall not be construed to apply to any other Health Net plans and Members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid Members by law and regulation.

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